A blog about home birth, pregnancy, childbirth, motherhood and all that good stuff.
(blog formerly named What Ifs and Fears are Welcome)

Monday, July 15, 2013

Home vs Hospital: The Equipment

Home birth midwives carry with them certain items to use in
case of an emergency - b/c no matter how low risk a mom might be, emergencies
can and do happen in childbirth and as such, they need to be prepared. I've
heard or read many, many times from mothers/fathers/couples that have chosen
home birth (or freestanding birth center) that “their midwife carries with them
all the necessary equipment in case an emergency arises.” So I want to present
a clear cut list for each setting of the equipment available in case of an
emergency.

There is a slew of equipment needed and provided in both
situations that I am not going to get into - such as gauze pads, chux pads,
sterile gloves, etc. What I'm focusing on is the equipment used either to
detect issues or for life saving measures.

Here's what a
(typical) certified home birth midwife will bring with her to a home birth:

Fetoscope
or Doppler (or both) - to detect the heart rate of the baby

One
oxygen tank

Infant
mask (used with oxygen tank)

Adult
mask (used with oxygen tank)

Blood
pressure cuff

Suturing
items - to stitch tears for the mother

Thermometer
- to check for fever for mother, which can indicate uterine infection

Lidocaine
- to numb mom locally while she is being stitched up

Pitocin
- in case of postpartum hemorrhage

Methergine
- in case of postpartum hemorrhage

Bulb
syringe - to clear airways of the baby, especially in case resuscitation
is needed

IV
equipment - if mom needs antibiotics in case of GBS or prolonged rupture of membranes

Pegnancy and labor records and charting, including blood type - in case of transfer, to ensure accuracy
and increase speed

A
midwife may or may not have an assistant with her

Midwife
should be current in the following skills:

Neonatal
Resuscitation (chest compressions and mouth-to-mouth)

Basic
Life Support (some may have Advanced Life Support training)

I would ask your midwife ahead of time to make sure she
carries (at least) these above items and has (at least) those certifications. The items should be in good working order, drugs should not be expired and midwife should be very familiar with exactly how to use each of these items and medications. Be your own advocate! Don't be afraid to ask questions ahead of time.

Now keep in mind, if
the midwife is not certified she will not have access to things like Pitocin
(or any medications), Oxygen, an IV, etc or any item that could get her in
trouble with the law for practicing medicine without a license (at least, she
will not have legal access to such items).

Ambulance:

A Paramedic will have the knowledge, skill and certain
equipment to be able to help in the case of an emergency. However, while a
Paramedic can certainly provide life saving support, they should not be
considered a fool proof back-up plan. Quoting a Paramedic: “We can do neonate
intubations but we do them SO seldom that it’s not a skill all medics are up to
par on. This goes for babies & pregnancy in general. In an emergency
childbirth scenario where minutes can make the difference in life and death,
NOTHING in an ambulance can save a baby; it can only be a very temporary
bandaid while we drive as fast as we can to the closest hospital.”

Response Time:
In a non-emergent transfer, travel time or response time will likely not be an issue. However, being "5 minutes from the hospital" may not be close enough when minutes can make the difference between a perfectly healthy life and death or neurological damage or injury or blood loss resulting in a transfusion or hysterectomy. Regardless of the scenario, emergency or not, a home birth transfer will take much longer than 5 minutes to get a laboring woman in her home (or birth center) to a hospital, in the right hands at the hospital, admitted, monitored and ready for a doctor to deliver a baby. I address this in my first blog post under the section "Is Our Hospital Really Close Enough" giving the example of a home birth transfer I attended as a doula; it was a very eye-opening experience for me.

Hospital:

All of
the above listed home birth equipment and medications, plus…

Electronic
Fetal Monitor (EFM) - this detects the baby’s heart rate and the contractions.
EFM vs Doppler gives nurses a much clearer picture of the baby's heart
rate to make sure baby is getting all the oxygen baby needs. Heart rate
variability is normal for the baby but it's important to know when changes
to the heart rate occur in relation to when contractions happen. A heart
rate of 155 BPM might sound healthy and wonderful when checked every 10
minutes or so but with decels at the end of a contraction, it can be a
serious sign of distress. The decels may be so slight that unless you are
looking at a print out (the EFM strip), you would not know they are
happening.

An
endless supply of oxygen

Cytotec
- for postpartum hemorrhage

Vacuum
and/or forceps (though forceps are not common anymore) - if the baby’s
health depends on immediate delivery, a vacuum can be used to help guide
the baby through the birth canal while the mother pushes

A
skilled team of nurses
and doctors that are current in the following skills (these skills are frequently used either on the job or through
hospital drills):

Neonatal
Resuscitation

Advanced
Life Support

Intubation
(and obviously the equipment for such) – provides a much more effective
way to oxygenate a person (of any age) compared to resuscitation

Also keep in mind, to be trained in Neonatal Resuscitation or
Life Support every few years and practicing only on a dummy is very different
than using those skills on-the-job in a true emergency, on a real mother or
baby. In a hospital, you have other sets of eyes and hands to help, to shout
direction or take over in case someone freezes or forgets under pressure, you
have a back-up for your back-up for your back-up. They will be able to tend to
baby AND mother at the same time, if needed.

From a nurse midwife student: "Not only is there a team full of certified, competent people, but in a hospital, they are running dystocia drills or practicing for other obstetric emergencies. These are people who have practiced working together, who have assigned roles, and in addition to all the drills, have seen their share of real emergencies. They not only have a pediatric and adult code teams, but depending on size and type of hospital, they may also have OB rapid response and code teams as well,as they do in my hospital. It's a well oiled machine."

Nurses will keep a watchful eye on mother/baby in the
hospital not just during the immediate postpartum period but for the
length of their stay, checking vitals and looking for signs of infection,
breathing complications, arrhythmia, postpartum hemorrhage, seizure, undetected
birth defects, etc.

It is true that an Operating Room may or may not be
available immediately when an emergency c-section is needed. In some cases, a
doctor can have a baby born via cesarean in less than 5 minutes, including
travel time from the Labor and Delivery Room to the Operating Room. In other
cases, it may take longer depending on the availability of the Operating Room,
anesthesiologist and obstetrician. However, the added commute from a home or birth
center will certainly not help facilitate a c-section any quicker – in addition
to travel time, the hospital must do its due diligence to admit the mother and monitor
the baby and mother before performing any emergency surgery.

5 comments:

Hospitals surely differ, but out here at our prep course they told us in a true emergency they can have the baby safely out by section in 3 minutes max. We are at a major urban teaching hospital tho - can't vouch for others but just wanted to note it!

There is another blog post I wrote about unexpected labor complications and a few women shared stories of needing to be sectioned immediately and their babies were born in less than 4 minutes.

Regardless, being at home only adds more time on the clock. A baby in need of a life saving cesarean section will certainly not get the c-section faster if the mother is at home vs if she is already in the hospital. That was something very eye opening to me as a birth: the transfer time. It's one thing to say "our house is so close to the hospital" and another to be in the moment with an emergency transfer.... when a mother in labor gets to a hospital, even if she is pre-registered it still takes time before the baby can be delivered. They have to do their own monitoring and such before they can take action like performing a c-section.

I wanted to encourage you to keep writing and let you know that I appreciate your blog! I am having my second baby in a hospital after a bad experience with a freestanding birth center (postpartum hemmhorage, partially seperated placenta, 4 manual removals... very scary!) I just wanted to let you know I included a few of your posts on my blog and hope that's okay :)http://thehealthshock.com/2015/06/03/why-i-decided-against-home-birth/(In this post)